Post navigation

Should progressives oppose the health-care reform bill?

Why would a progressive oppose the health-care reform bill that’s now on the table? Three main reasons have been offered.

One is that the bill will require (most) people to have health insurance. This means some low-income Americans, those who don’t get health insurance from their employer or from the government (Medicaid or Medicare), will have to buy insurance from a private insurer. They’ll receive a subsidy to help offset the cost, but for most the subsidy will be only partial; a new insurance policy may cost a family as much as 8% of its income. These people, the argument goes, will therefore be worse off.

I don’t see the logic in this. Unless you’re a libertarian, I’m not sure why you’d believe forcing people to spend money on something that’s in their self-interest — and calculations show that it clearly is in the interest of those who need health-care services — makes them worse off. Think of the Social Security and Medicare tax. It amounts to forced savings of nearly 8% of earnings — perhaps twice that, since the portion employers contribute arguably comes out of pay. But there is a benefit that outweighs the cost: guaranteed income and health care during retirement years, plus the accompanying peace of mind.

A second argument against the health-care reform bill is that health insurance companies and pharmaceutical firms will benefit. But opposing the bill on the grounds that it will benefit the already-powerful amounts to prioritizing equality over the well-being of America’s poor and lower middle-class (and others too, since the reform will sharply limit insurers’ ability to refuse or restrict insurance to people with preexisting conditions or greater likelihood of illness).

Here I think progressives ought to turn to John Rawls, the most influential moral philosopher of the past century. Rawls’s full view of justice is complex, and I won’t attempt to explicate it here. (There’s a nice summary in chapter 6 of Michael Sandel’s new book Justice.) The key point is that we ought to care more about the absolute well-being of the poorest than about the gap between the rich and the poor or between the powerful and the powerless. Rawls didn’t feel inequality is irrelevant, but he argued that it is secondary. This, he suggested, is what we all would believe if we thought about it carefully enough. I think he’s right.

The third reason for opposing the bill is a belief that it can be replaced by a better one in the not-too-distant future. Unfortunately, as many commentators have pointed out (Hacker, Klein, Krugman, Skocpol, Starr), experience suggests that is very unlikely.

Related

I’m surprised by the naive arguments you make in this post. The post is unworthy of you; you understand the issues better than this. What is compelling you to make such a flimsy and dishonest argument?

The bill is a wealth transfer from the poorest to the richest, at the point of a government gun. Period. Arguing that the poorest ought to be paying the richest anyway strikes me as 1) irrelevant and 2) incorrect. It is not at all clear that paying for health insurance will benefit all poor people — your link to Gruber’s figures only addresses average medical expenses, while the freedom to choose whether to buy health insurance allows workers with lower medical costs to opt out and save their money for other essentials. In addition, for those working at the minimum wage, this extra expense will mean a significant reduction in the de facto minimum wage in the US.

Your argument trivializing “equality” is also bizarre: you of all people should understand that economic inequality results in lower absolute, not relative, welfare for the disadvantaged. You conflate absolute income with absolute welfare as though inequality doesn’t shape the environment in which wealth is converted to welfare. This is not something you would have done in any of your other posts. So what’s going on, Kenworthy? Why the desperate attempt to defend this despicable bill?

Is there an assumption that people who don’t qualify for medicare/medicaid are able to afford mandatory insurance (no matter how cheap)? Sure, *if* they get seriously ill or injured, they would be better off to have it, but if they do not succumb to ill fortune, they are worse off at a day-in-day-out kind of level. Most poor people would rather roll the dice, no matter how illogical it appears to those who are employed at a living wage level or higher.

I recently was able to find a new job that moved me into a living wage category. But before that I earned 17K per year (single person). At that rate, I qualified for no assistance of any kind, yet even with living on cabbage and beans, I could scarcely pay for routine expenses with rent at $450 per month for a studio apt, car upkeep for my beater of 170k miles (no public transportation), gas, a phone, groceries, replacement clothes when mine wore out, etc. I did not have internet access, or buy music or books…no luxuries. I regularly found myself with $17 to $40 left over per month. If any little thing went wrong, I was in tears and unable to pay for the issue (ex…I drove around with a broken windshield for 2 years because the cost of a new windshield was so high and what little money I had left over was so precious that I opted to roll the dice and hope that nothing else hit the windshield).

Poor people make these “illogical” decisions daily. Heck, I *had* insurance but couldn’t afford the deductibles. So I went $900 into debt because my broken hand was under the deductible cost and my replacement glasses weren’t covered. My solution was go go back to college and get a student loan that was at least at a lower interest rate than the credit card. That lower rate debt is what gave me the differential to afford taking care of my car, afford to keep a phone, and afford to see the doctor on occasion.

Now, I haven’t studied the compromised, mandatory health insurance deal at all. It just doesn’t seem that interesting to me because calculating/talking/arguing about its effects and hoping to have accounted for every variable is just not the same as having to live with the consequences of being poor on a daily basis. You can’t get blood out of a turnip so exactly where are the poor who are still above government assistance level supposed to come up with the money to afford this? Anything short of a single payer, gov’t sponsored system is going to likely to leave these not poor enough people worse off regarding their daily existence.

I now earn 22K per year (FWIW I have 2 years of graduate school in neuroscience under my belt, but that, alas, was over 12 years ago, so am considered unqualified to compete with the new crop of graduates in this new world of excessive creditialitis–keep purchasing those degrees). So I now can actually have a savings account. I’m paying off my student loans, dropped out of college because getting yet another degree is absurd at the age of 45, and I’m grateful that I can now buy a few luxuries like internet access and books. But I will always remember what it was like to not have enough money to cover daily needs, and to feel like a failure. I also “knew” that the wealthy were always wondering how to repackage sweet sentiments to delay the the discovery that their words were betrayed by their actions– which strongly imply that you should just die already because you are surplus population.

Anyway….sorry for the long diatribe, but the gist of my rant is that for the poor who are no-man’s land, this whole mandatory insurance debate is just not interesting. It’s irrelevant because we just don’t have what it takes to play the game called life according to what appears reasonable and logical to our better paid brethren. Decide whatever you want, it matters not one whit. Rome fell too, but the already impoverished farmer living at the far margin of that society felt little impact. If you have nothing, there’s nothing to lose, even life becomes irrelevant. Living this one day to the maximum is where it’s at because you have absolutely no chance to plan for the future or save a danged thing. We roll the dice.

…CEO’s openly refused to stop recissions, and in general told Obama and the Dems in Congress to STFU. Given that they now have 30-odd million more forced customers, their behavior can be expected to get far, far worse than it was.

It’s the power imbalance and the distribution of income that is keeping health care from being reformed.

But I don’t want to talk philosophy, I want to talk specifics.

I’m chronically ill and use a lot of medical services. If I don’t want to end up in the poor house I need a way to control my co-pays and deductibles. I’m retired and on a fixed income. Because of this need I’m in a Medicare Advantage plan. Let me lay out my argument that this is a strange kind of reform.

I want to start with a premise: People that pick Medicare Advantage plans do so because traditional Medicare’s co-payments and deductibles are too expensive for them. The closer these plans come to traditional Medicare, with there ever growing co-pays and deductibles, the greater the incentive is not to see a doctor.

These plans are subsidized but they won’t be when health care reform is passed because the subsidies will help pay to get more people insured. Fair enough, but where does that leave people who sign up for these Medicare Advantage plans so they can afford health care? The government is giving incentives with one hand and taking them away with the other. This isn’t reform, and for the chronically ill its an early foot in the grave.

For instance, my Medicare Advantage plan, which isn’t much different than most generic plans has raised the cost of all my services and dropped others completely. No more dental services, a night in the hospital which cost $80 last year costs $160 this year. Non generic medicines have also doubled in price. Closing the donut hole isn’t doing me any good. So I ask, where are the savings? where is the reform? Health insurance and pharmaceutical companies are making out like bandits while the 8 million people trying to hold their medical cost down are getting closer to the grave.

I was one step from the hospital because I was trying to juggle my medicines. I only got a stay of execution because Obama raised the income threshold for veterans to receive services. Now I can get my really expensive medicines from the Veteran Administration, but there are millions of people juggling health services who haven’t caught a lucky break.

BTW, I’ve argued that if the democrats pass a bill that turns out not to be reform that will help the republicans get back into power. I can’t think of any reason someone would vote republican after the mess they left the country in but voters will smell a rat if the democrats try shuffling off a health care package as reform that’s not reform at all.

I’ve known several people who have died because they didn’t have health insurance, or ended up with chronic health problems that could have been avoided.

I think those of you who oppose this plan have a moral issue. Tens of thousands die every year, many more have unnecessarily worsening illnesses. This will largely stop under the reform. What is your moral case for continuing this carnage?

Of course you don’t need to get health insurance at all, I think the fee is $700.

Did you read Ceci’s comment? The part about “$17 to $40 left over per month”? $700 a year on a $22k income is a disastrous expense — where is that money supposed to come from?

I think those of you who oppose this plan have a moral issue. Tens of thousands die every year, many more have unnecessarily worsening illnesses. This will largely stop under the reform.

1. I haven’t seen or heard any evidence to support this statement.

2. Feudalism and slavery might also reduce the rate of avoaidable death due to medical neglect, because slaveowners have an incentive to keep their property in working order — of course, being kept alive is hardly incompatible with being horribly abused, which is the fate of the underclass under either feudalism or our current debt-peonage.

In other words, reducing overall morbidity is not an airtight argument — if this bill results in greater inequalities (in wealth, and therefore social and political capital as well), it is not worth it even if it results in slightly improved medical outcomes overall in the short term.

“the reform will sharply limit insurers’ ability to refuse or restrict insurance to people with preexisting conditions or greater likelihood of illness”

It’s important to make explicitly clear (even though for some reason most people don’t) that this bill does far more than just stop insurers from refusing preexisting conditions — It makes it so that they can’t charge any higher a price for preexisting conditions.

That’s a huge difference. If an insure can’t refuse you due to a preexisting condition, but they can charge you $100,000/year for it, that’s not nearly as good as if they can’t refuse you and they can’t charge you any extra.

What amazes me about the liberals who are against the individual mandate is that they think they are doing lower income people and the middle class a favor.

Like if they succeed they can say, “There, I helped you, you now have no health insurance. No need to thank me.”

The bill makes health insurance inexpensive enough (or free with Medicaid) for the poor and middle class that virtually anyone is better off having health insurance than not. This is especially true in light of positional/context/prestige externalities

If everyone in your peer or reference group is forced to buy health insurance, then they all have less to spend on housing, so housing prices are lower. They all have less to spend on cars, so you can purchase a less expensive car without feeling too low prestige, etc., etc., for most goods.

If everyone in your peer or reference group is forced to buy health insurance, then they all have less to spend on housing, so housing prices are lower.

Yes, very good: the poor have even less to spend on housing, meaning that the last few parcels of urban real estate currently rented by the poor are razed and converted to luxury condos to be purchased as fifth or sixth homes for the insurance CEOs.

Your analysis is childishly simplistic. As I’ve already said multiple times above: inequality actually decreases the ABSOLUTE welfare levels of the poor, because they are competing in the same market for the same scarce goods as the rich. This isn’t theoretical: look at any major US city to see the increasing destitution of anyone working at a minimum-wage job as housing prices continue to rise thanks to the ever-increasing prosperity of the ultra-wealthy and their completely elastic demand for more and more real estate.

They all have less to spend on cars, so you can purchase a less expensive car without feeling too low prestige, etc., etc., for most goods.

Ah yes, the reliable old “Cadillac welfare queen” canard. You’re doing a great job of channeling Ronald Reagan — appropriate, since this is exactly the sort of “trickle-down” legislation he would have loved.

I hope that Serlin’s comments above give you pause. When you’re making common cause with someone who argues that reducing the income of the poor is good for them (because they’ll have less to spend on their fancy cars, don’t you know), you really ought to rethink your political commitments.

(me) I think those of you who oppose this plan have a moral issue. Tens of thousands die every year, many more have unnecessarily worsening illnesses. This will largely stop under the reform.

(Picador) 1. I haven’t seen or heard any evidence to support this statement.

The whole point of health care reform is to reduce the rivers of blood running through our streets, which privileged folk like you are unaware of. Shame on you.

Here is the Natl Inst of Health report from 2003. Look to the right, you can read it online for free. In this study, they estimate 17K dead per year from lack of health insurance. It is much worse now of course (more studies below). This report is particularly good on how lack of insurance leads to death and chronic illness. It is several hundred pages.

How serious is your appetite for reality on this issue? Or are you just spewing your ideology, with indifference to the suffering of the American people?

I used to make 17K per year which was about 2K per year less than a living wage in my town. But if life went perfectly and I needed no new clothes, shoes, no eye exams, dental care, no car break downs (once again, no public transport here and housing near enough to work to walk or bike in costs $300 per month more than the figure I quoted for rent above), I was able to save $17-$40 bucks per month.

So, where exactly would I be expected to get the $500 – $800 from to pay for this health care plan? Just how long can any person live with nothing ever going wrong? And suppose that I did have a major illness. How exactly am I supposed to pay even those reduced medical costs?

BTW, now that I make 22K per year, I could afford to pay for the plan, but once again I can’t afford to use it. I can’t have anything go wrong in my life with my car or needing new clothes.

FWIW, I’m middle aged. I’m stuck here. This life isn’t temporary. If Malcolm Gladwell is right and it takes 10 years of practice to achieve mastery in an area, then even if I took on student loans and went back to school for a masters degree, I’d be 55 years old before I got skilled enough to be middle class again and I’d be 60 before I got the loans paid off. So no saving for retirement for me whichever scenario I chose.

So, how exactly is this low cost mandatory insurance helpful? No blood in this turnip…makes no difference one way or the other. Looks like word games and theory chess to me.

This doesn’t reduce the income of the poor. It increases the income of the poor substantially, by providing hundreds of billions in increased subsidies and new free Medicare.

It doesn’t increase income inequality; it decreases it. It takes progressive taxes and uses them for a very large subsidy and free health insurance for the poor, and middle class.

But in addition to increasing the income of the poor and middle class it does shift consumption from high externality conspicuous consumption to low externality, higher utility, inconspicuous consumption. For more on this, please see this brief article by Cornell economist Robert H. Frank (who no one should call a conservative — he advocates highly progressive tax rates up to 70%):

Ok…last post, and a really long one at that (sorry). This is more general than the topic presented in this article, but since I seldom frequent this forum, I thought I go ahead and say everything on my mind. Pardon the non-economics speak.

———————–
Years ago when I was more gainfully employed in the sciences, I experienced an event with one of the lab rats that shifted my thinking permanently. Before this day I never really had to deal with the dirty business of killing them or causing them damage. A lab tech did that part of the process for me. My job was to harvest about 1/4 inch of sciatic nerve, tease out the individual fibers and perform in-situ hybridizations on them with mRNA probes. But on this particular day, the rat escaped. We trapped him in a corner and prepared to throw a towel on him. He did not opt to go meekly to his fate. He hissed and jumped, lunging at us trying to bite. His life may have been trivial to us, but he was fighting for all he was worth. Ultimately, his heroic efforts were for naught. He died anyway and I cut out his nerves to perform my experiments. But I never again felt so cavalier about designing experiments that used animal tissue. They were like a crop to us, born and raised to be maimed or killed in order to understand a physical/biochemical etc. process. But now it had been driven home to me that they felt fear, pain, and anger. I was thinking elegant, theoretical concepts, but they were having to *live* it, every mistake, even every success I made caused them pain and death for many.

What I’m trying to say is, while it’s well and good to theorize and to conceptually understand the variables and predicted consequences of your decisions, it most certainly pales to the process of actually having to live it. Now that I’m no longer considered valuable to society (as proven by my low salary and inability to find a better job), I realize that the poor are like the rats in my experiments. Politicos and economists ponder theories about how to repackage theoretical concepts in such a way as to slowly shift society toward a more sustainable economy. But by and large, they are buffered from having to experience the consequences of those changes if they are wrong. So, which theory is right? Run the experiment and find out. Collect historical data. But remember that there are people living the consequences. It is not data to them. It is real.

I know that people will say that of course they understand this. Heck, I did too, even before that fateful encounter with that rat. But just as a cliche achieves power when you finally find yourself in the middle of an event, there’s no substitute for the visceral, gut punch of being trapped in the middle of living the consequences. No way out, no amount of cleverness or fighting will help. 15K of debt, might as well be 50k or 100K when you’re making 17K per year. You can’t save for an illness, to buy any asset that will hold it’s value, for college, for retirement…nothing. What difference does it make, really? You can’t pay for the mandatory insurance and you can’t pay for the doctor bills whether you do or don’t have the insurance. The only way you can go is down. I guess one could try to say that it’s a positive that maybe with all that debt you might finally qualify for food stamps.

In a way, it’s an experiment to tell people (particularly the middle aged people) to get multiple roommates, shower at the YMCA, walk to work, live in your car, get a camp stove….but the reality is that it often just doesn’t work in the real life competition for a decent job.

Over and over, theory types tell me that I’m naive. But in a world of finite resources, how can any economy keep growing? “It’s not a zero sum game!” they decry. But really, given the interconnectedness of the all the players/variables in the entire *finite* system, how can it not be? Some ships really never get floated. Heck some are so weighted down that they are swamped by the tide and sink! The pie shape is so warped that some pieces are not only not growing, they’re shrinking. Success grants the successful continued success. “Them that has, gets.” Somebody *has* to lose. That’s how the game is structured. I lost and given the present economy and the misfortune of living in nowhere, MS nothing I can do will alter it.

Changing a person’s life costs money (or requires long term support and subsidy) and takes time (and allows for them to make some mistakes without reaping permanent failure). Society seems only willing to do this for youth and those 18-20 somethings ideally must be subsidized by parents covering their health insurance, car repairs, and a portion of their college and internship living costs. But once your parents die, or you’re middle aged, you’re on your own.

Further…(pondering on a general note yet still ultimately connected), how can we continue to increase automation and efficiency without reducing our population? It looks to me like we’re setting up a larger number people to be losers. How many more people will end up similar to me? Economics says that there will always be winners and losers, but can we afford the risk of increasing the number of losers and society having to carry them along despite their not being a fully contributing citizen?

Money, like blood, must circulate. Right now, only the middle class and higher are in the circulation zone. The poor are swapping the same money to and fro. There’s little oxygen entering the world we inhabit. If blood doesn’t circulate throughout the body it could be due to heart attack or stroke, it can also cause gangrene…death of the extremities. How much can be cut off and still have a body capable of functioning? Do we really want to go there? We’re acting like only the brain matters, or only the head and torso. But how much of all that’s available to do in life can such a stunted body really experience?

Back on topid…this insurance plan may protect those borderline middle class types that don’t have insurance. But there’s a large number of people too “rich” for government assistance, but too poor to be helped by this health care band aid. So for people similar to me, this is an irrelevant experiment. My contention is that this pool of people is large enough and increasing that it will prove to be an irrelevant experiment overall.

I’m an uninsured diabetic. My health is otherwise excellent and I’ve never needed any significant medical care. My insulin costs about $90 a month, I use my $.10 needles 20 times before throwing them away, and I buy my test strips online for one-fifth the retail price, i.e., the price that all the insured people pay.

I thought I was getting by pretty well without insurance until I was in a car accident, head-on at 25 mph. I thought my life was over. But the seat belt and airbag (neither of which I chose to buy because it was a rental car) allowed me to walk away without serious injury. A couple of acupuncture sessions and I was good as new.

I’m now all in favor of forced insurance. I should have had it before the accident and would have if I could have purchased it. The only reason I escaped a financial disaster was that years ago we forced car companies to include seat belts and air bags in all cars. And remember the automobile makers arguing against those regs? Yup, they all said poor people wouldn’t be able to afford cars anymore.

When somebody tells me that they can’t afford to insure their health for a few hundred bucks (or even more) per year, I wonder: why do they think it should be their choice? Shouldn’t we all be required to insure our bodies? Why does everybody accept the idea of forced auto insurance and forced fire insurance, but many have difficulty with forced health insurance? Isn’t your health more important than your car or home?

I enjoyed this discussion, in particular Cici’s words. As a graduate student living around 2x the poverty line in an extremely expensive area, I can attest to such issues.

However, this issue alone is insufficient to assail this bill. This bill does have incredible provisions which help the currently uninsured and those who will be crowded out of private insurance in coming years. Most of the reforms in this bill are absolutely necessary. I agree that those living just a a small multiple above the poverty line (like myself) who are not eligible for Medicaid and can barely make ends meet as it is are justifiably upset. However, there is still plenty of hope that the final bill will have higher subsidies for these people who, as Cici says, are “too rich” for a full subsidy, but too poor to make ends meet. Yes, even those “politicos” (at least liberal ones) are aware of this problem, and it is certainly one of the points of contention. Let us hope that those more liberal Congressmen can add more subsidies for these people.

But in any case, if you cannot afford either the insurance or the fine, nothing is going to happen to you. No one is going to be arrested for evading the health fine. Thebest you can do would be to complain to your Congressman — remember, minor (though major in impact) amendments like increased subsidies are routinely added to bills.

By general point is that we should all still accept this bill, since the alternative of doing nothing is far worse. And I still disagree that it’s better to play Russian Roulette by going uninsured. You can’t see what’s coming, and that includes bankruptcy from health care costs borne of a random accident.

By the way, a table of the proposed premium contributions by income as a percent of poverty level, along with a full discussion of the bills:

….but in any case, all great reasons for a single-payer system. Sadly, the numbers always show that a majority of Americans would support a health care system “like Medicare” for all Americans financed through income taxes, but because of all the scare tactics put out there, this is described as “socialism”. Sigh.

Health insurance is a good thing and, if the development of public financing of medical care in Canada, Australia, and Switzerland is any guide, this legislation is an important step in the right direction. But it would be naive to believe that we will see as a result of its enactment significant increases in average life expectancy or reductions in mortality (infant mortality may prove an exception).

1) The insurance companies get blasted by everyone…but by my best account they operate at a 2 – 3% profit margin (some as low as a half %)…I can’t figure this out (btw, i am not in the insurance industry and I do believe that my premiums are outrageous compared to my use of healthcare)…what is a fair profit?

2) Why is it so easy for individuals to understand the concept of home and auto insurance (the less claims I have the lower my rates will be…the cheaper my car or home is the lower my rates will be)…but they run to the doctor every time “little Johnny” has the sniffles because the “co-pay” is only $10…while “rationing” is dirty word perhaps we should all start practicing a little “restraint”

3) To “Orlando Pain Clinic”…I believe that the most comprehensively covered people in America are Union workers and Government employees…I don’t think you will find alot of republicans in that group

4) I believe the biggest challenge to implementing this healthcare initiative will be the 50 to 100 million more who will join the ranks of the 30 million this Bill is aimed at covering…simply put, it will be much easier for companies with 50 to 200 employees to pay an 8% penalty tax (it is easier and cheaper to control the size of your pay-roll than to manage the labyrinth of Insurance policies)…I don’t mean to sound like Glenn Beck but companies will go this route and jobs will be lost (that will mean that a department with 10 employees each making $30k will be reduced by 1 person to cover the $21,000 (8%) insurance penalty)

5) How do you fix the problem of needless tests…ask any Dr if they run too many tests and tests that are to “eliminate doubt”…they will tell you yes but they must cover their butts…the suburban housewife that walks into the ER with a migrain and need to for a shot of demerol will routinely get a battery of tests and an MRI…because every doctors nightmare is the patient that is sent home only to suffer an aneurism…then the local news runs a story about the husband and kids who are left behind and all could have been prevented with a $500 to $2000 MRI…I am afraid the governments program will solve this by capitating illness sub groups (ie. a laceration in the ER will be covered for $500 and that will cover the room, clinician and supplies…likewise a pacemaker will be covered for $20,000) the determination will be dictated by cost.

In my crystal ball I see the future of healthcare being provided to the masses (poor and lower middle class) by Walmart…more than likely they will set up clinics within there stores (already cheap and available overhead)…they will hire physicians who are willing to work for cheap (probably foreign)…the bulk of the services will be provided by nurse practitioners (also hired cheap)…and they will gain instant access to rural parts of our country that have always perplexed healthcare providers…services will be basic and fast…post treatment care will be the responsibility of the patient…No drugs will be prescribed that are NOT generic and will be purchased at the Walmart pharmacy (which will negotiate massive discounts from generic pharma)……………and prepare to hear the following, “welcome to Walmart Health, your 12th in line to see the nurse but here is a pager…feel free to do some shopping and we will beep you when it’s time for your appointment”……………….(Think about it, the first 1.5 million patients already work for Walmart…thats 5% of the uninsured)

I really have no answers…just questions and concerns…I am interested in the comment of you people who are far smarter than I.